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Authorized Representative Form

Overview

In certain cases, you may need to have an authorized representative communicate with your Division of Family Resources (DFR) caseworker or Medicaid staff. In order for the State to discuss your case or history with your representative, you will need to give written permission to the State. The following list describes the permissions required:

  • If you want someone to act on your behalf in applying for benefits or act for you on an ongoing basis with your DFR caseworker, you must complete an Authorized Representative for Health Coverage Form. You can get this form directly from DFR.
  • If you want your DFR caseworker to be able to share your personal or health information with others, you must complete the Authorization for Disclosure of Personal and Health Information Form.

Authorization for Disclosure of Personal and Health Information Form

 IHCP Personal Representative Authorization Form

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